Case 17

Submitted by Neha D. Shah MPH, RD, CNSC, CHES

A 31-year-old man was diagnosed with mild left sided ulcerative colitis.

Treatment commenced with oral mesalamine and mesalamine enemas. However, symptoms of abdominal pain, bloating, diarrhea, and hematochezia persisted until he was admitted to the hospital. There, imaging and endoscopic evaluation revealed severe ulcerative pancolitis without evidence of terminal ileal involvement. Infliximab 10 mg/kg was administered intravenously during the hospital stay. He was discharged on oral prednisone 40 mg once daily with the plan to taper in the outpatient clinic and continue maintenance infliximab.

In clinic, he reports unintentional weight loss of 35 pounds (lbs) from his usual body weight of 150 lb in three months. He attributes the weight loss to not being able to tolerate a diet in setting of abdominal pain, diarrhea, hematochezia, gas, bloating, and cramping prior to his hospitalization.

Since his hospitalization, he has had formed bowel movements overall, at times, streaked with blood. The frequency of bowel movements has reduced to one bowel movement a day. The gas and bloating are reduced as well. No reports of chewing difficulty, dysphagia, early satiety, reflux, nausea or vomiting.

 The patient was formally referred to see the IBD dietitian in clinic for a nutrition assessment.

 What are nutrition-related clinical indications to refer a patient to see an IBD dietitian present in this case? 
Decreased intake from oral diet
Unintentional weight loss or sarcopenia (loss of muscle) 
Micronutrient deficiencies (or risk of)